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Medical Conference 2012 - John Sciarra, MD

Medical Conference 2012 - John Sciarra, MD

Endometriosis Foundation of America
Medical Conference – 2012
Grand Rounds
John Sciarra, MD

I have no financial or ethical disclosures relative to the content of this talk. That is important. I am from Northwestern and our medical school is located in downtown Chicago in the shadow of the John Hancock building, a large building in the center of this picture. This is the picture of the Prentiss Women’s Hospital and Maternity Center of the Northwestern University. It is a maternity hospital opened in 2008. We deliver about 12,000 to 13,000 patients annually and do a comparable amount of gynecologic surgery. In the department there are 50 full-time faculty members and about 100 volunteer faculty members. We have 48 residents and 15 Fellows. That gives you some idea as to the institution where I am presently located.

I would like to just begin this talk by reviewing with you a historical perspective of hysterectomy. Hysterectomies have been with us for a long time, since the beginning really of the 19th century. Although the initial attempts at hysterectomy were really not very successful, successful meaning the patient did not survive more than two weeks. The first successful vaginal hysterectomy was 1824. The first successful abdominal hysterectomy is somewhat unclear. There were reports from England in the mid-1840s of cases being done, but the first successful abdominal hysterectomy in the United States was done in 1853 by Walter Burnham in Lowell, Massachusetts. He subsequently went on and did 14 more cases and published a paper on 15 hysterectomies and that is sort of a landmark paper in the United States for hysterectomies.

The first caesarian hysterectomy was done by Poro in 1876, and then after the advent of anesthesia and asepsis the first radical hysterectomy for cervix cancer was done by Shauta and Wertheim in Vienna in 1898. In the early 1900s all of the hysterectomies were supracervical hysterectomies until 1929 when Richardson at Johns Hopkins did the first total abdominal hysterectomy. That brought in an era of controversy for the 1940s, 50s and 60s in relation to hysterectomy operation. Total hysterectomy vs total hysterectomy and it is still continuing. In those days the rationale for the total hysterectomy was for the prevention of cervix cancer which was the leading cancer in women in the 1940s and 1950s in the United States. This was before the advent of the pap smear and the identification of cervical dysplasia. To some degree that story still continues.

The first laparoscopic hysterectomy was recorded by Harry Reich in 1989 and then there are a lot of other firsts after this; the first robotic hysterectomy, the first single incision hysterectomy, etc. But this is some idea of the background of this topic.

In the United States for the past several years there have been about 600,000 hysterectomies. This is a figure that has been quoted over and over again. About 90 percent of these hysterectomies are for benign disease. It is the most frequent and non-obstetrical major surgical procedure and the rate of hysterectomy in the United States, which is the highest in the industrialized world, is 5.4 per 1,000 women annually. Think of it in this way, 16 to 25 percent of all adult women have had a hysterectomy and one in three women have had a hysterectomy by age 60. That is the US figure, in Canada it is one in four, similar to us.

If we compare our rate of hysterectomy with two other countries, I picked out Italy and Norway; you see that we do many more of these procedures than the other two countries, as I mentioned 5.4 per 1,000. Because of figures like this there have been many, many concerns that probably we are doing more surgery than we should be doing since our people in the US are not any healthier than the people in Norway, but yet they are doing only one quarter the number of major surgeries that are being done in the United States. This is just background information.

One of things that we never talk about is the mortality of hysterectomy. Actually the figures are not easy to obtain. This is a paper from the CDC that Bert Peterson and his colleagues published in the Gray Journal in 1985. They looked at the US statistics and the abdominal hysterectomy mortality was one in 668, vaginal hysterectomy mortality was one in 2,608 but this included all patients, cancer patients as well as pregnant patients. If you take out the 61 percent of the deaths from cancer and from pregnancy the conclusion of the paper is that for benign disease the mortality rate is 6/10,000. That is about the best figure that we have. We have some recent information in relation to surgical morbidity and mortality that I think is important. It was published in Lancet in October of last year and it was a study of 225,000 surgical cases, excluding cardiac and thoracic surgery, and the authors looked at pre-operative anemia as a risk factor in surgery. They found very dramatically that in patients that were operated on that were anemic pre-operatively, the mortality and the morbidity rate, the 30-day mortality and morbidity rate was twice that of patients that were operated on with normal hemoglobin levels. I think that is an important paper and important figure now in terms of counseling patients that when you operate on someone that is anemic, even for benign disease, there is an increased morbidity and mortality. You may say that does not happen at Lenox Hill but the evidence is clear. This is from 201 hospitals around the world and over a quarter of a million cases were reviewed.

Why should we be interested in alternatives to hysterectomy? There are at least three reasons. There may be many more. New surgical and non-surgical techniques are now available. Minimally invasive surgical techniques have been introduced and have been widely accepted. But the most important reason I think is that the public is asking for alternatives to traditional abdominal surgery. This is certainly true in Chicago. It is true in New York. It is true in Los Angeles. It may not be as true in the southern part of the country but certainly in the area where I live and where you live this is an important consideration.

You do not have to go far to find out why. If you look on the internet there are many different women’s groups that are talking about unnecessary hysterectomy. This is just one, it is the National Women’s Health Network and this is the introduction to their website. “The National Women’s Health Network believes that unnecessary hysterectomies have put women at risk needlessly and that health care providers should recognize the value of a woman’s reproductive organs beyond their reproductive capacity and search for hysterectomy alternatives before resorting to life-changing operations”. This is just one statement. There are many, many more like this.

The AAGL position statement on hysterectomy is also an important one for us to be aware of, it was published in 2010. This is the AAGL statement, “It is the position of the AAGL that most hysterectomies for benign disease should be performed either vaginally or laparoscopically and that continued efforts should be taken to facilitate these approaches”. That is the benign part of the statement. “Surgeons without the requisite training and skills required for the safe performance of vaginal hysterectomy or laparoscopic hysterectomy should enlist the aid of colleagues who do or should refer, and that is the key word, patients requiring hysterectomy to such individuals for their surgical care”. This caused quite a bit of discussion at the American College as you can imagine and I think is still causing discussion about this statement of the AAGL.

In the United States in recent years what we have seen is a decrease in abdominal hysterectomy and an increase in laparoscopic hysterectomy including robotic hysterectomy, an increase in sub-total hysterectomy for a variety of reasons and an increase in vaginal hysterectomy. Here are the figures from our own hospital for the last five years, four or five years, and you can see the lines for vaginal hysterectomy, which are the light lines, are fairly constant. The red line is in the increase in robotic hysterectomy and the green line is the increase in laparoscopic hysterectomy. The yellow line is the decline in abdominal hysterectomy. This is a scenario that has been repeated, I think, in many hospitals throughout the United States.

What about alternative therapy for hysterectomy? It began in the 1990s with the introduction of endometrial ablation first generation and second generation endometrial ablation. Also in the 1990s uterine artery embolization was introduced. In the decade of the 90s between 1990 and 2000 myomectomy returned as a very fashionable operation, whether it be abdominal, laparoscopic or hysteroscopic. We will talk about this in a moment. In the year 2000 cyromyolysis was introduced but was pretty rapidly abandoned as a technique that was not terribly effective. The Levonorgestrel IUD was introduced ten years ago and has become very popular and very valuable in our treatment. MRI-guided focused ultrasound was introduced in the United States in 2004 and we will talk about that later. Then, in 2007 a variety of uterine artery occlusion techniques, laparoscopic, vaginal and other techniques began to appear. Then for 30 years we have been looking at medical therapy for fibroids and only recently have we had some significant breakthroughs in this area and we will talk about that later in the hour.

The two areas that I am going to concentrate on are benign disease for fibroids and abnormal bleeding. Of course, hysterectomies are done for pelvic relaxation and for endometriosis and chronic pelvic pain but these are less in number than hysterectomies for fibroids and for bleeding so I am going to concentrate on the first two. These are the things I will cover with you in the next 30 to 40 minutes: myomectomy, uterine artery embolization, MRI guided focused ultrasound, endometrial ablation, Levonorgestrel IUD, some experimental surgical techniques and some new medical therapies.

For those of you who are interested in fibroids I refer you to this recent addition of the Gray journal and a very fine article by Bill Parker from UCLA looking at the utility of MRI for managing women with uterine fibroids; because MRI is becoming now the Gold Standard for the evaluation of uterine fibroids particularly when looking at methods for alternative therapy.

Myomectomy has been with us for a long time, over 50 years from the time of Sir Victor Bonney, done to preserve the uterus and to preserve fertility. As you all know there is an increased possibility of uterine rupture during pregnancy or vaginal delivery. It is really important to stress this in patients that are going to have a myomectomy that are in their reproductive years.

One of the things that the literature tells us is that myomectomy is not a perfect operation. The recurrence rate is 20 to 25 percent. The reoperation rate is up to 25 percent, and although the conversion to hysterectomy is less than one percent, the morbidity of myomectomy is equal to that of hysterectomy. In some instances some of the reports may even be greater than morbidity of hysterectomy.

Recently, the past five years or so, there has been a discussion in the literature relating to minilaparotomy myomectomy as an alternative to laparoscopic myomectomy. This is a paper from Mark Glasser published in 2005 and these are his words, “Minilaparotomy myomectomy is a safe, effective minimally invasive alternative to laparoscopic myomectomy. Early discharge and return to normal activities is comparable to laparoscopy and is far more cost effective. It affords the ability to palpate the uterus and close the myometrial defect easily with a standard three-layered closure making it particularly suitable for gynecologists with limited laparoscopic suturing skills”. There is at least one randomized study from Italy where they randomized patients to laparoscopic myomectomy and minilaparotomy myomectomy and basically the results are exactly the same in terms of outcome. It is an alternative that we should be aware of.

This is a typical picture of a submucous fibroid taken through the hysteroscope. With the advent of hysteroscopic myomectomy we have another alternative. This is now an established procedure. It is extremely effective for both submucous and even for some intramural fibroids. Relatively few complications are reported except for fluid overload. This is really quite amazing in the thousands and thousands of hysteroscopic myomectomies that have been done. The complication rate is really quite low. With the new hysteroscopic morcellators that are on the market and that are coming on the market, should make this procedure faster and easier.

Uterine artery embolization was introduced in the mid-90s by Ravina. It was first used for the treatment of symptomatic bleeding fibroids. This is an interesting story. He decided that he did not want to operate on his patients with fibroids because they were terribly anemic. He was looking for an alternative to give them time to build up their hemoglobin and hit upon the idea of the uterine artery embolization. His idea was to wait for three months, let the patients build up their hemoglobin and then it would be safe to operate on them either vaginally or abdominally. Well, at the end of three months many of the patients said, “You know, we feel just fine, we’re not bleeding anymore and we don’t want the surgery. We don’t want the surgery”. Remember this story because it is going to repeat itself in this year. The technique became quite popular. Main indication being menorrhagia and it is now possible with the present techniques to embolize even the small vessels that are going directly to the fibroid rather than the uterine artery itself. It is a technique that is widely used. It is going to be completed most of the time. There is relief of the menorrhagia 80 to 90 percent of the reported cases. There is a reduction in the size of the fibroids most of time and there is even a reduction in uterine size most of the time. As you know, it is an out-patient procedure and complications are relatively few but occasionally are serious.

In an effort to follow patients with uterine artery embolization a group of hospitals got together and formed the FIBROID registry. We participated in this. This was a three-year follow up of 2,112 patients that was published in 2008. It was done by questionnaire and there was really quite a good response. The mean symptoms scores were improved, the quality of life scores were improved and that is what we expected.

To look at the downside of these 2,112 patients the hysterectomy rate was ten percent, the myomectomy rate was three percent and the repeat embolization rate was two percent, and there were some cases of premature ovarian failure in older patients. Here is some data that you can quote and use for patients that are considering this procedure because it is not 100 percent. The ten percent of these patients within three years will end up having a hysterectomy.

The question that often comes up is what about pregnancy following uterine artery embolization? There have been several reports. This happens to be one from England where a large number of patients, 174 patients, were followed for up to seven years. In this group 98 desired pregnancy and 42, about half of them, became pregnant. The spontaneous abortion rate was high, 24 percent, resection rate was high as you would expect in a high risk group of patients like this but the authors came to the conclusion that it was reassuring that patients could indeed get pregnant following uterine artery embolization.

The most recent technique that was approved by the FDA was the use of MRI guided focused ultrasound for uterine fibroids. This is a way of providing thermal injury selectively to fibroids in a non-invasive manner. The patient lies on a table as you saw there. “The MRI guidance allows the temperature of the treated fibroid to be measured during each sonication to maximize complete treatment and to minimize injury to the surrounding tissues”. It is the same type of non-invasive surgery that is used by the neurosurgeons for example, and it is being used in other areas now including the treatment of breast tumors in Japan – so it is an interesting new technology. “Treatment usually takes about three hours and is done on an out-patient basis. There is minimal discomfort”, which is quite interesting “because the process is coagulative necrosis (not ischemic necrosis)” as in patients with uterine artery embolization. I am sure you know in patients that have had artery embolization that they do have a lot of post-procedure discomfort. With MRI guided focused ultrasound, since there is no ischemic process, it is all coagulative, there is minimal discomfort.

Here is a gadolinium scan of a fibroid before and after therapy. You can see that after therapy there is absolutely no perfusion, no blood flow through the fibroid. This is the basis for treatment because the fibroid will then shrink. This technique was approved in the United States in 2004. It had been used in Israel and
Europe earlier. The main indication, symptomatic fibroids, especially fibroids causing pressure symptoms, the ideal fibroid treatment with this technique would be a fibroid that was pressing on the dome of the bladder. Several thousand patients have been treated both in the US and elsewhere and fibroids up to 20 cm in size have been treated, although most, most fibroids are much smaller in size. As I mentioned a moment ago the process is central coagulative necrosis and shrinkage and 80 percent or more of patients report improvement.

There are relatively few long range studies with this technique. This happens to be one paper that was published two years ago from the _________ Institution of a 12 month follow up of 130 patients that were treated between 2005 and 2009. Eighty-eight percent of the patients reported relief of symptoms and the conclusion of the authors was that, “This technique is a non-invasive treatment option that can be used to effectively and safely treat uterine leiomyomas and delivers significant and lasting symptom relief for at least 12 months”. We do not have any long range studies on this technique.

Endometrial ablation was introduced in the 1990s and initially the technique was hysteroscopic ablation with the resectoscope or ablation using a laser. This was a laborious procedure and was not generally adopted by our professionals until the second generation endometrial ablation techniques were introduced. These have now become almost universal because there are many devices that are on the market and they are all effective. The interesting thing about endometrial ablation is that not only can it be done on an ambulatory basis but it also can be done in many instances in the office without having the patient go to a surgery center or a hospital.

The goal of endometrial ablation is to destroy endometrium to at least 5 or 6 mm. This will destroy the basal arteries and the spiral arteries and this is the reason that bleeding does not occur after this technique. Second generation techniques have proved to be extremely effective for controlling abnormal bleeding, especially in women who failed medical management and who have completed child bearing. The important thing today is that reduction of menstrual flow is adequate symptom control and achievement of amenorrhea is not really important. In the early days of endometrial ablation when we were using a resectoscope our goal was amenorrhea. This is not really necessary, it has been shown that it is not necessary as long as one can reduce the menstrual flow.

Here is just a list of some various devices that are on the market; there are liquid filled balloons that are very effective and ThermaChoice was the first one to be brought to market. Cryoablation is an interesting technique. It was the first technique that was licensed for office use. Hydrothermal ablation can be used in the patient with larger uterus or irregular uterus and works well. Bipolar radiofrequency ablation has become extremely popular, at least in the mid-west and I will talk more about that in a moment from our own experience. And microwave ablations are primarily popular in the United Kingdom and Canada. This is a study from our own institution of the NovaSure. We are following the procedure a year after the procedure we ask patients about their menstrual function. There were a small percentage of patients that were amenorrhea but not very many. Most had reduced menstrual flow or were eumenorrheic. There was a re-operation rate in one year of three percent. We do not do that any longer. The patient satisfaction rate with this technique and with the other techniques that are on the market – patient satisfaction rate is usually pretty high, 90 percent or more.

This is a study from the United Kingdom, the National Health Services hospitals, looking at hysteroscopic resection and second generation endometrial ablation with the thermal balloon or with microwave from 1989 to 2004 over that five year period. You can see that as the second generation techniques became available the hysteroscopic resection stared dropping off. But more importantly, in the same study you see here the hysterectomy rate for abnormal bleeding and the endometrial ablation rate – as the endometrial ablation rate goes up the hysterectomy rate comes down. We have similar data from the United States. This is for the period 2002 to 2009 and these are hysterectomies for menorrhagia. You can see that the numbers are going down and this is in part attributed to endometrial ablation. It may be due to other things as well.

The endometrial ablation procedures allow patients to avoid hysterectomy in 80 percent of the time, in the first three years. But effectiveness of endometrial ablation decreases with time and patients should be aware of this. After five years there is a 25 percent hysterectomy rate. This is one study.

This is another study that was published in the Green Journal of “Hysterectomy vs Endometrial Ablation for Dysfunctional Uterine Bleeding”. There were 237 patients who were randomized and in 24 months both techniques were effective in relieving symptoms, but the hysterectomy group, as you can imagine, had more adverse events. However, at 48 months 32 of the 110 endometrial ablation patients required re-operation and most of them required hysterectomies. Endometrial ablation is a great technique for a few years but the effectiveness decreases with time. Therefore, when ACOG came out with their recommendations in 2007 these were the two things they highlighted; patients who chose endometrial ablation should be willing to accept normalization of menstrual flow, not necessarily amenorrhea as an outcome, and hysterectomy rates associated with endometrial ablation are at least 24 percent within four years following the procedure. This is important information in counseling patients.

What about medical alternatives for abnormal bleeding rather than hysterectomy? Hormonal therapy has been with us for a long time. It has never been terribly successful but the two things that seem to be valuable at the moment are Levonorgestrel intrauterine device and tranexamic acid. I will just summarize both of these for you.

The Levonorgestrel IUD was originally introduced as a long acting intrauterine contraceptive device but subsequently it proved to be very useful in the management of patients with abnormal uterine bleeding because of the direct progestational effect on the endometrium. The only important thing in relation to the use of the IUD for abnormal bleeding is that endometrial pathology must be ruled out, hysteroscopy and/or endometrial biopsy prior to the placement of the device. It is highly effective. It can be removed at any time with return of fertility. It has a proven safety profile with many million women using this device worldwide. In general, periods are shorter, lighter and less painful, so it is a really good alternative.

This is a study that was published this year looking at 92 women. It is a small study but a nice three year study. Ninety-three percent of the women were successfully treated and six women did require a hysterectomy for various reasons. While the Levonorgestrel IUD is not 100 percent, it is pretty good. The conclusion of this author was, “The Levonorgestrel intrauterine device following an endometrial biopsy is an effective treatment for menorrhagia due to benign causes and could be an alterative to other forms of medical and surgical therapy”.  

What about the IUD vs endometrial ablation? There was a Cochrane Review a few years ago and in both instances there was no difference in patient’s satisfaction. There was less reduction of blood loss with the IUD than with endometrial ablation but both groups of patients seemed to be satisfied. The quality of life was equal.  Andy Kaunitz did a review in the Green Journal recently with a meta-analysis and the findings were very similar.

I would like to speak briefly about the tranexamic acid and this is the first study from the US. It is a multi-center double blind placebo controlled trial of 300 women for three menstrual cycles. The endpoint was mean blood loss reduction. The mean blood loss prior to therapy was 80 ml per cycle qualifying these patients for menorrhagia and it was reduced to less than 50 ml per cycle over the three months of the study. The conclusion was that four grams per day of tranexamic acid was both effective and well tolerated. Something we knew from the international literature because it has been used in Asia and it has been used in Europe for a long time. The only downside of course is the cost and so it has not become, even though it has been on the market now for two years, it has not become widely adopted by the gynecologic community.

What about experimental surgical techniques and new medical therapies? These are the last things that I am going to talk about. I am sure you are familiar with all of the things I have already talked about. There are many techniques that have been tried for uterine artery occlusions. It started about five years ago; either laparoscopic occlusion, vaginal artery ligation, or an interesting device, that is the uterine artery clamp with Doppler monitoring that was slowly, in a non-invasive way, clamped down on the uterine arteries transvaginally for about six hours. Then this would cause – it would be similar to a uterine artery embolization. Patients had to be give epidural anesthesia because it was uncomfortable but it did result in fibroid reduction and a reduction of bleeding. It is still under investigation. In my opinion, it does not look terribly promising but people are still pursuing this technique.

The Halt procedure is one that is on the horizon. Halt stands for hysterectomy alternative. This is a radiofrequency ablation that is done through the laparoscope. The concept is that there is intra-abdominal ultrasound, similar to the ultrasound that the surgeons use for liver tumors, to outline the fibroid and then an electrode is placed percutaneously under laparoscopic and ultrasound guidance with the surgeon controlling both the ultrasound transducer, and the electrode. What happens is the fibroid is treated. There is thermal destruction and this is followed eventually by reabsorption. The present clinical trial is limited to six fibroids per patient under therapy. This may mean that the utility is somewhat limited but I think the procedure is going along well and it may be something that we will see on the market in the reasonably near future.

New medical therapies however, I think are the most promising. We have had hormonal therapy for a long time. We have had GnRH agonists that have been used for fibroid treatment but the problem with the GnRH agonists is 1) the side effects; 2) they can only be used for a limited period of time; and 3) when you stop the medication there is a rebound. The fibroids return and they often return larger than they were when the treatment began. New medical therapies have been focusing on other approaches, and there are two: the first relates to use of aromatase inhibitors and the second relates to the use of progesterone receptor modulators.

This is the first study that was published pf the use of aromatase inhibitors. It is a study from Greece. There were 35 premenopausal women with symptomatic fibroids. They were treated for three months prior to surgery. There was a 56 percent decrease in volume plus an increase in hematocrit. It looked like this might be a good approach. This approach is still being continued particularly with one of the investigators at Northwestern. I think it may hold some promise for the future.

However, the most promising medical therapy at the moment is with the use of progesterone receptor modulators. Some years ago it was shown that progesterone is a growth factor for uterine myoma cells. It is not a growth factor for uterine muscle cells. That makes it sort of a unique situation and ulipristal acetate is the compound that seems to be the most effective. Ulipristal acetate is a modification of the ________ molecule. This was a study that was presented at ESHRE last year and subsequently published in Fertility and Sterility. It was a randomized placebo controlled double blind phase two trial of the UPA in patients with fibroids that were bleeding. There was a significant reduction in fibroid mass. Marked reduction in menstrual bleeding and no effect on ovarian function and estrogen levels were unaffected. There were no adverse effects except for some endometrial stimulation. This is important because all progesterone receptor modulators are associated with some degree of endometrial proliferation. The pathology is cystic glandular dilatation. Here is the picture of it. You can see that there is not much affect on the stroma but that the glands are indeed dilated. The pathologist who has written the most about this is Spitz has written, “The most common histological finding is cystic glandular dilatation… This histology has not been previously encountered in clinical practice and should not be confused with endometrial hyperplasia. The endometrial thickness is related to this cystic glandular dilatation”.

The good news is that this condition is totally reversible once the medication has been stopped. There is a recent paper that I think will be a very important paper. It was published in the New England Journal of Medicine on February 2nd of this year from Europe. Jacques Donnez was the lead author and it was a large multi-center study of several hundred women. A phase three study of ulipristal acetate and there were three trial groups. The first group was the patients that had bleeding fibroids and were treated with the UPA. The second group was patients with bleeding fibroids that were treated with a GnRH agonist. The third group was patients treated with a placebo plus iron therapy. All three groups were anemic at the start. All three groups were planned to have surgery at the end of three months. In the UPA group 98 percent of the patients stopped bleeding within a week and at the end of three months there was a 50 percent reduction in the fibroids. Many of the patients said, “You know, I feel fine, I don’t want to go ahead with surgery”. So the investigators followed them not knowing what to expect, thinking that there would be a rebound effect of the fibroids as we have seen with GnRH agonist. But after two, three, four, six months there was no increase. The fibroids remained small. The medication has now been licensed for use in Europe for patients with bleeding fibroids. Recently, a phase three study of the same preparation has been started in the United States. It has several centers so we will have some data from our own country in the near future.

So we do have, now, on the horizon a viable, possible treatment, medical treatment for uterine fibroids, which I think is very exciting.

Despite that, Hysterectomy is still a good operation. Many studies have shown that the quality of life of women increases substantially after hysterectomy for benign disease. I will show you some of these in a moment. Vaginal hysterectomy and laparoscopic hysterectomy are associated with an improved post-operative course over abdominal hysterectomy. These are the three take home points that I would just like to stress.

Quality of life after either laparoscopic hysterectomy, vaginal hysterectomy or abdominal hysterectomy – many papers that have looked at this summarized in this article in the European Journal in 2008. But a paper that I think is a very good one is Ray Garry’s report from the United Kingdom. It was published in the British Medical Journal where he looked at 876 of his own patients and looked at health, looked at body image, looked at sexual activity and found that the quality of life increased at six weeks for the laparoscopic hysterectomy group patients but at one year it did not make any difference on the route of hysterectomy the quality of life patients of all different types of hysterectomies was greatly improved.

Alternatives to hysterectomy and these are some points that I think are important. Patient counseling is extremely important in discussing alternatives to hysterectomy with patients. While hysterectomy is 100 percent successful in treating benign uterine pathology, alternative methods are not 100 percent. I have given you some of the background data and the evidence that you should know if you are going to recommend alternative therapies to patients. The option should be presented on the basis of reported evidence and as you know now we do have pretty good evidence for most of the techniques. Patients should be involved in the decision making process.

All of that information is available now as Dr. ____ mentioned on the Global Library of Women’s Medicine. This internet product is an evolutionary product with a six-volume series that I used to edit called Gynecology and Obstetrics, the Loose Leaf series. We now have it on the internet and it is available free and without advertising. This is the way to access it: www.glowm.com. There are 500 chapters on women’s medicine authored by really expert people with 40,000 references. We update it on a regular basis and it is linked to PubMed and the FDA website. We have a video library of surgical procedures, a video library of ultrasound procedures. We have two complete books, one on post-partum hemorrhage and one on repair of vessel vaginal fistulas. We have patient information and brochures, and as I mentioned, it is available free and no advertising. The editor, me, may get nothing for doing this. I do it because I want to do it. All the authors have contributed work without compensation. I think it is a really important contribution particularly for our doctors from other countries. We have 173 countries now where doctors access this site on a regular basis, up to three million or more hits per month and they download hundreds of thousands of pages every month so it is very gratifying for me to see how this has evolved. All the information I have talked about today is available on this website.

I would like to thank you for inviting me to be with you this morning and today. I will show you one last picture of the moon over downtown Chicago, right over our medical center. Thanks a lot.